Washoe Country School District

July 31, 2014

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Medical Plans
 

 

 PPO PLANS

 
The District offers two PPO Plans. They have the same benefits, deductibles, coinsurance, and co-payments. The difference between the two plans is one plan uses a Saint Mary’s based provider system (Saint Mary's PPO) and the other plan uses a Renown based provider system (Renown PPO).
 
 
Below are some brief highlights of the PPO Plans:
 
  • Self-Funded Comprehensive Major Medical Plans
  • Worldwide Service   
  •  $500/Member, $1,000/Family Annual Deductible when Preferred Providers are used
  • $1,500/member, $3,000/family Annual Deductible when Non-Preferred Providers are used
  • $3,000 Annual Out-of-Pocket Maximum/Member; $6,000/Family for Preferred Providers
  • $6,000 Annual Out-of-Pocket Maximum/Member; $12,000/Family for Non-Preferred Providers
  • $25 Co-payment for Primary Care Physician visit (Co-payment is not subject to Annual Deductible)
  • $35 Co-paymant for Specialist Office visit (Co-payment is not subject to Annual Deductible)
  • Inpatient Hospital Admissions must be Pre-certified prior to being admitted
  • Emergency Hospital Admissions must be Pre-certified within 72 hours after being admitted
  • Elective Outpatient Surgical, and any procedures, services and/or supplies that exceed $10,000 must be Pre-certified
  • $2 Million Annual Maximum Benefit
  • GAP Plan Coverage is provided to all eligible Members
    • The GAP Plan (through American Fidelity Insurance Company) is designed to help cover some of your out-of-pocket expenses with the PPO Plans. It will pay up to $1,000 per inpatient hospital confinement, up to $200 for certain outpatient services, up to $100 for emergency room visits and up to $25/doctor visit/x-ray or lab (limit of $125/family). If you cover your dependents, they will also have the GAP Plan coverage. There are specific exclusions to this plan, so please read carefully the GAP Plan brochure in your packet. (Please note that the “Pre-Existing Conditions” exclusion has been waived.) To be reimbursed by the GAP Plan, you’ll need to submit to American Fidelity the “Explanation of Benefits” (EOB) you receive from the PPO Plan administrator along with an American Fidelity GAP claim form.  
       
       
  • Hospitals:
    • Saint Mary's PPO includes Saint Mary's Regional Medical Center and Northern Nevada Medical Center 
    • Renown PPO includes Renown Regional Medical Center and Renown South Meadows Medical Center
  • Claims Administrators:
    • Saint Mary's PPO - CDS Group Health
    • Renown PPO - Hometown Health
  • Provider Panels:
    •  Saint Mary's PPO  - Saint Mary's Preferred Health Care Network - (775)770-6900 or (800)433-3077
    • Renown PPO - Hometown Health Provider Network - (775)982-3232 or (800)336-0123
  • Prescriptions - Both Plans provide prescription coverage through CVS/Caremark -  (866)844-2220 (see Prescription Drug Plan webpage)

Please check the Saint Mary's Preferred Health Care Provider Directory if you covered by our Saint Mary's PPO Plan to see if your current provider is listed or to find a Preferred Provider.

Please check the  Renown's Hometown Health Provider Directory if you covered by our Renown PPO Plan to see if your current provider is listed or to find a Preferred Provider.


Please refer to  the PPO Plan Document for a complete description of the PPO Plans. 

 

 EPO PLANS

 

The District offers two EPO Plans. They have the same benefits and co-payments. The difference between the two plans is one plan uses a Saint Mary’s based provider system (Saint Mary's EPO) and the other plan uses a Renown based provider system (Renown EPO).
  • Self-funded Exclusive Provider Organization (EPO)
  • Members must reside in Northern Nevada Service Area or North Lake Tahoe Area
  • $3,000 Annual Out-of-Pocket Maximum
  • No Annual Deductible
  • $25 Co-payment for Primary Care Physician  visit
  • $30 Co-payment for Specialist Office visit
  • No claim forms
  • All Members must select a Primary Care Physician
  • Referrals for all services must be obtained through your Primary Care Physician, except Chiropractic and OB/GYN services
  • No benefits will be paid if you do not use a Contracted Provider
  • If outside the service area, only Emergency and Urgent Care services are covered
  • $2 Million Annual Maximum Benefit
  • GAP Plan Coverage is provided to all eligible Members
    • The GAP Plan (through American Fidelity Insurance Company) is designed to help cover some of your out-of-pocket expenses with the EPO Plans. It will pay up to $1,000 per inpatient hospital confinement, up to $200 for certain outpatient services, up to $100 for emergency room visits and up to $25/doctor visit/x-ray or lab (limit of $125/family). If you cover your dependents, they will also have the GAP Plan coverage. There are specific exclusions to this plan, so please read carefully the GAP Plan brochure in your packet. (Please note that the “Pre-Existing Conditions” exclusion has been waived.) To be reimbursed by the GAP Plan, you’ll need to submit to American Fidelity the “Explanation of Benefits” (EOB) you receive from the EPO Plan administrator along with an American Fidelity GAP claim form.    
    •  
  • Hospitals:
    • Saint Mary's EPO includes Saint Mary's Regional Medical Center and Northern Nevada Medical Center 
    • Renown EPO includes Renown Regional Medical Center and Renown South Meadows Medical Center
  • Claims Administrators:
    • Saint Mary's EPO - CDS Group Health
    • Renown EPO - Hometown Health
  • Provider Panels:
    •  Saint Mary's EPO  - Saint Mary's Preferred Health Care Network - (775)770-6900 or (800)433-3077
    • Renown EPO - Hometown Health Provider Network - 775/982-3232 or 800/336-0123
  • Prescriptions - Both Plans provide prescription coverage through CVS/Caremark -  (866)844-2220 (see Prescription Drug Plan webpage)

Please check the Saint Mary's Preferred Health Care Provider Directory if you covered by our Saint Mary's EPO Plan to see if your current provider is listed or to find a Preferred Provider.

Please check the  Renown's Hometown Health Provider Directory if you covered by our Renown EPO Plan to see if your current provider is listed or to find a Preferred Provider.

Please review the EPO Plan Document for a complete description of the EPO Plans.